What exactly does Medicare cover, and what must enrollees pay for out of pocket? This is a common question — rest assured you’re not alone trying to figure it all out.
When an enrollee is covered by “traditional” or “original” Medicare, certain kinds of care are not covered at all: routine dental care, hearing aids and glasses, long-term care, and alternative therapies like acupuncture.
Some good news about traditional Medicare, however, is that more than ever, it’s focused on covering preventive care services — thanks in part to the Patient Protection and Affordable Care Act of 2010.
Most preventive services are covered by original Medicare with no copays or deductibles:
- Abdominal aortic aneurysm screenings
- Alcohol misuse counseling
- Bone mass measurements
- Cardiovascular screenings
- Colon cancer screenings (colorectal)
- Depression screenings
- Diabetes screenings
- Diabetes self-management training
- EKG screenings
- Flu shots
- Glaucoma tests
- Hepatitis B shots
- HIV screenings
- Medical nutrition therapy services
- Pap tests and pelvic exams
- Preventive Visits (two types — one when you’re new to Medicare and one each year after that)
- Pneumococcal shots
- Prostate cancer screenings
- Smoking cessation
Here’s what original Medicare won’t cover, or strictly limits:
- Routine dental care. There’s no coverage for basic dental health care such as checkups, cleanings, or fillings, and there is no coverage for dentures. Even if Medicare has paid for you to have a tooth pulled in preparation for a medical procedure, you will be responsible for the cost of your dentures should you need them.
- Complementary and alternative therapies. These kinds of treatments include homeopathy, naturopathy, acupuncture, holistic therapies, midwifery, and herbal medicine. Most chiropractic care is not covered.
- Most care received outside of the U.S.
- Long-term care. Medicare does not cover indefinite, long-term care, nor assisted living nor adult daycare. It covers short-term recovery from an illness or injury, including care in a nursing facility. Medicare does pay for recovery in a skilled nursing facility (SNF) after a three-day hospital stay and will also cover home health care (note: this is not round-the-clock care). Hospice care is also covered.
- Hearing aids or the exams for prescribing/fitting hearing aids.
- Personal care or custodial care: such as help with bathing, toileting and dressing (unless homebound and receiving skilled care) and nursing home care (except in a skilled nursing facility if eligible).
- Housekeeping services to help you stay in your home, such as shopping, meal preparation, and cleaning (unless you are receiving hospice care).
- Most non-emergency transportation.
- Routine foot care: A foot exam is covered every six months only for people with diabetic peripheral neuropathy (DPN).
- Most vision care. This includes eyeglasses (except when following cataract surgery) and examinations for prescribing or fitting eyeglasses.